* He outlined an extraordinary management structure with no one in overall control of the facility and a "culture of secrecy".

* Dr Draper, Ms Harrison and Mr Skelton each sought to avoid responsibility by "pointing the finger" at the other two, Mr Lander said in his report.

* Mr Lander said it was "astonishing" that relevant ministers were unaware of the extent of the problems at the home, which included incidents of rough handling of patients, excessive use of restraints and a high level of injuries.

* But the commissioner found on the evidence, "to a large extent, what was occurring at the Oakden Facility was unknown to ministers and chief executives".